Citation Nr: 22061908 Decision Date: 11/03/22 Archive Date: 11/03/22 DOCKET NO. 17-27 886 DATE: November 3, 2022 ORDER 1. Entitlement to service connection for hypertension is granted. 2. Entitlement to secondary service connection for right foot pes planus is granted. 3. Entitlement to a total disability rating based on individual unemployability (TDIU) from April 28, 2011, is granted. 4. Entitlement to statutory housebound special monthly compensation (SMC) from April 28, 2011, is granted. REMANDED Entitlement to an initial increased rating in excess of 10 percent for right foot plantar fasciitis prior to February 19, 2015, is remanded. Entitlement to an initial increased rating in excess of 20 percent for right foot plantar fasciitis since February 19, 2015, is remanded. Entitlement to an increased rating in excess of 30 percent for asthma and sarcoidosis is remanded. FINDINGS OF FACT 1. Giving the Veteran the benefit of the doubt, the Veteran's hypertension had its onset during active service. 2. Giving the Veteran the benefit of the doubt, the Veteran's right foot pes planus is proximately due to or the result of the Veteran's service-connected right foot plantar fasciitis. 3. Giving the Veteran the benefit of the doubt, from April 28, 2011, the Veteran's service-connected posttraumatic stress disorder with mood disorder (mental health disorder) by itself precluded the Veteran from being able to secure and follow substantially gainful employment. 4. From April 28, 2011, the Veteran has now had a single service-connected disability rated as 100 percent disabling and has had additional service-connected disabilities independently ratable at 60 percent disabling which are separate and distinct from the 100 percent service-connected disability and involve different anatomical segments or bodily systems. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension have been met. 38 U.S.C. §§ 1131, 1154, 5107; 38 C.F.R. § 3.303. 2. The criteria for entitlement to secondary service connection for right foot pes planus have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. From April 28, 2011, the criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.341, 4.3, 4.16, 4.19. 4. From April 28, 2011, the criteria for entitlement to statutory housebound SMC have been met. 38 U.S.C. § 1114(s); 38 C.F.R. §§ 3.350, 4.25. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1988 to December 1990. This matter originally came before the Board of Veterans' Appeals (Board) from a June 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a March 2020 Travel Board hearing before the undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript is associated with the claims file. This matter has previously been remanded multiple times by the Board for further development, most recently in September 2021. A September 2021 Board decision denied the issue of entitlement to a TDIU since February 19, 2015. That issue was appealed to the United States Court of Appeals for Veterans Claims (CAVC), where a Joint Motion for Partial Remand (JMPR) was granted in August 2022. This matter is again before the Board. 1. Entitlement to service connection for hypertension is granted. The Veteran believes that entitlement to service connection for hypertension is warranted. Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. See 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for certain chronic diseases, including hypertension, when such disability is manifested to a degree of 10 percent or more within one year of discharge from service. See 38 U.S.C. §§ 1101, 1112(a); 38 C.F.R. §§ 3.307, 3.309; see also VAOPGCPREC. 2-03 at paras. 2-3 (May 22, 2003). When chronic diseases are at issue, the second and third elements for service connection may be established by showing continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the veteran will receive the benefit of the doubt. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776, 781-82 (2021). The first element of service connection is the existence of a current disability. The clinical evidence documents the Veteran's current diagnosis of hypertension. See June 2013 VA Examination. Therefore, the first element of service connection has been established. The second and third elements of service connection are the incurrence or aggravation of a disease or injury and a causal relationship between the current disability and the disease or injury incurred or aggravated during service. Service records show high blood pressure readings, including readings of 142/96, 138/94, 130/100, 128/88, 126/90, 134/90, and 146/90. See June 2005 STR Medical. The Veteran likewise reported that high blood pressure readings were recorded in the service records. See April 2011 Statement in Support of Claim. Medical records from 2010 also show that the Veteran had high blood pressure during service. See March 2010 Medical Treatment Record. Medical records additionally show high blood pressure readings, similar to the readings listed above, from service up until a diagnosis of hypertension was made in 2009. Following the diagnosis in 2009, the Veteran continued to have hypertension up through the appeal period. See May 2005 Medical Treatment Record; April 2009 Medical Treatment Record; January 2010 Medical Treatment Record; April 2010 Medical Treatment Record; June 2013 VA Examination; March 2017 CAPRI. The Board gives the above evidence great probative value. Therefore, the second and third elements of service connection for hypertension have been established. Based on the evidence of record, a continuity of symptomatology for hypertension has been sufficiently established. Additionally, no medical reason has been offered to reject the evidence concerning a continuity of symptomatology. In sum, the evidence has shown that symptoms of hypertension began during service and have continued up though the appeal period. Therefore, giving the Veteran the benefit of the doubt, entitlement to service connection for hypertension is granted. 2. Entitlement to secondary service connection for right foot pes planus is granted. The Board notes that during the pendency of the appeal for an initial increased rating for right foot plantar fasciitis, a relationship between the right foot plantar fasciitis and the Veteran's right foot pes planus was reasonably raised by the record. See June 2022 C&P Exam; Morgan v. Wilkie, 31 Vet. App. 162 (2019) (schedular rating concepts, including secondary service connection, are critical components of the duty to maximize benefits well before reaching an extraschedular analysis). As such, the issue is before the Board. Secondary service connection is merited if there is (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the veteran will receive the benefit of the doubt. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch, 21 F.4th at 781-82. The first element for secondary service connection is evidence of a current disability. A 2022 VA examination shows a diagnosis of right foot pes planus. See June 2022 C&P Exam. Therefore, the first element for secondary service connection is met. The second element for secondary service connection is evidence of a service-connected disability. The Veteran is service connected for right foot plantar fasciitis. Therefore, the second element for secondary service connection is met. The third and final element for secondary service connection is medical evidence establishing a nexus (i.e., link) between the current disability and the service-connected disability. A 2022 VA examination found that the Veteran's right foot pes planus disability was directly due to or related to the Veteran's service-connected right foot plantar fasciitis because pes planus is commonly associated with plantar fasciitis. The pes planus was a progression of the service-connected right foot plantar fasciitis. See June 2022 C&P Exam. Given the evidence of record, the Board concludes that the evidence is at least in relative equipoise as to whether the Veteran's right foot pes planus is proximately due to or the result of the Veteran's service-connected right foot plantar fasciitis. Therefore, the third and final element for secondary service connection is met. Entitlement to secondary service connection for right foot pes planus is granted. 3. Entitlement to a TDIU from April 28, 2011, is granted. The Veteran believes that entitlement to a TDIU is warranted. A schedular total disability evaluation for compensation purposes may be assigned when the schedular rating is less than 100 percent, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For a TDIU claim, the issue is whether a veteran's service-connected disability or disabilities preclude the veteran from engaging in substantially gainful employment (i.e., work which is more than marginal, that permits the individual to earn a living wage). See Moore v. Derwinski, 1 Vet. App. 356 (1991). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the veteran. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. From April 28, 2011, the Veteran has had a 70 percent disability rating for a mental health disorder. During that period, the Veteran has had a single disability rated at 60 percent or more. See September 2021 Rating Decision Codesheet. Therefore, from April 28, 2011, the Veteran met the percentage threshold requirements provided in 38 C.F.R. § 4.16(a) for consideration of entitlement to a schedular TDIU. A schedular TDIU is available from April 28, 2011, if the Veteran was unable to secure and follow a substantially gainful occupation due to his service-connected mental health disorder during that time. After a review of the evidence of record, the Board resolves any doubt in the Veteran's favor and finds that the Veteran was unable to secure and follow a substantially gainful occupation due to a service-connected mental health disorder since April 28, 2011. The evidence shows that the Veteran only had a high school education. See February 2013 Medical Treatment Records. The Veteran stopped working prior to 2011. See June 2020 C&P Exam. The Veteran's work history included working in a warehouse and construction work. See November 2010 Medical Treatment Record. The Board previously found that since April 28, 2011, the Veteran's mental health disorder resulted in occupational and social impairment with deficiencies in most areas. The evidence recited by the Board revealed that the Veteran's mental health disorder resulted in depressed mood, anxiety, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Veteran had problems getting along with others. The Veteran could not be around the public, could not be around co-workers for more than a brief period, was easily angered and irritable, had impaired impulse control, and was violent towards property. Additionally, the Veteran could not perform activities within a schedule, had problems with regular attendance and being punctual, had problems understanding and carrying out detailed instructions, had impaired concentration and memory, and had problems with sustained persistence and maintaining attention. Finally, the Veteran had problems with handling stress, had difficulty adapting to stressful situations, and had suicidal ideations. See September 2021 BVA Decision. Based on the above, the Board finds that the evidence is at least in relative equipoise as to whether the Veteran's service-connected mental health disorder precluded the Veteran from engaging in substantially gainful employment since April 28, 2011. Therefore, entitlement to a TDIU from April 28, 2011, is granted. 4. Entitlement to statutory housebound SMC from April 28, 2011, is granted. A claim for increased disability compensation may include the "inferred issue" of entitlement to special monthly compensation even where the veteran has not expressly placed entitlement to SMC at issue. See Akles v. Derwinski, 1 Vet. App. 118, 121 (1991). Statutory housebound SMC requires a veteran to have a single service-connected disability rated as 100 percent and additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. See 38 U.S.C. § 1114(s). A TDIU based on a single service-connected disability can count as a single service-connected disability rated at 100 percent. See Bradley v. Peake, 22 Vet. App. 280 (2008). The Board finds that entitlement to statutory housebound SMC is warranted. Specifically, the Veteran is now in receipt of a TDIU from April 28, 2011, based solely on the service-connected mental health disorder. Additionally, from April 28, 2011, the Veteran has had a 30 percent disability rating for sinusitis, a 30 percent disability rating for asthma and sarcoidosis, and a 20 percent disability rating for a chronic right ankle sprain. Combined, these disabilities are ratable at 60 percent disabling. These disabilities are separate and distinct from the service-connected mental health disability and involve different anatomical segments or bodily systems. Therefore, entitlement to statutory housebound SMC from April 28, 2011, is granted. REASONS FOR REMAND 1. Entitlement to an initial increased rating in excess of 10 percent for right foot plantar fasciitis prior to February 19, 2015, and entitlement to an initial increased rating in excess of 20 percent for right foot plantar fasciitis since February 19, 2015, are remanded. The Veteran believes that higher ratings for right foot plantar fasciitis are warranted. The most recent Board decision found that a 2020 right foot examination was inadequate because it did not substantially comply with the Board's May 2020 remand instructions when it did not provide active and passive range of motion testing and did not explain why the required testing could not be conducted. The Board then remanded the issue for a new VA examination. See September 2021 BVA Decision. The new examination took place in April 2022. The Board finds problems with this examination. First, the examination appears to be internally inconsistent by finding both that there was pain with passive motion and that there was no pain with passive motion. Second, the examination found that the Veteran did not experience flare-ups of the right foot; however, this finding is inconsistent with the other examinations of record, which all found flare-ups. See May 2013 VA Examination; February 2015 C&P Exam; May 2020 C&P Exam. Third, the examination was unable to provide active and passive range of motion testing because isolating foot joint range of motion was outside the skill set of the examiner. Fourth, the examination noted the use of injections and medication for the right foot but does not appear to have considered the ameliorative effects of medication when evaluating the current nature and severity of the right foot disability. See Jones v. Shinseki, 26 Vet. App. 56 (2012) (when a Diagnostic Code is silent as to the effects of medication, VA may not deny entitlement to a higher disability rating based on the relief provided by medication). Additionally, the Board finds that relevant right foot examinations from 2013 and 2015 also have problems. See May 2013 VA Examination; February 2015 C&P Exam. The examinations did not provide any range of motion measurements and did not state whether there was pain on non-weight bearing. See Correia v. McDonald, 28 Vet. App. 158 (2016). Additionally, it does not appear that the examinations considered the ameliorative effects of medication when evaluating the current nature and severity of the right foot disability. See Jones, 26 Vet. App. at 56. Finally, none of the examinations of record have provided information concerning any convalescence required from the Veteran's right foot surgery. As such, there is currently insufficient medical evidence of record to make a proper determination on the issue. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). For these reasons, among others, a remand is needed for a new VA examination. 2. Entitlement to an increased rating in excess of 30 percent for asthma and sarcoidosis is remanded. The Veteran believes that a higher rating for asthma and sarcoidosis is warranted. The most recent Board decision found that a 2020 asthma and sarcoidosis examination was inadequate because it did not substantially comply with the Board's May 2020 remand instructions when it did not conduct the FEV-1, FVC, FEV-1/FVC, and DLCO (SB) studies and merely restated test results from 2010. The Board then remanded the issue for new VA examinations. See September 2021 BVA Decision. The new examinations took place in 2022. The Board finds problems with these examinations. First, the examinations did not perform exercise capacity testing and did not state why. Second, the examinations did not conduct DLCO (SB) testing, and although the examinations stated that it was not valid for the Veteran's particular case, the examinations did not state why the testing would not be useful or valid. See 38 C.F.R. § 4.96. Third, by not conducting the DLCO (SB) testing, the examinations did not substantially comply with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998). Fourth, the examinations found that the Veteran did not require the use of corticosteroids; however, the examinations did not consider/were unable to consider the Veteran's report that he believed that high dose corticosteroids were required, but his body would not allow him to take them based on adverse reactions to the corticosteroids. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); May 2016 Statement in Support of Claim. Additionally, the Board finds that relevant asthma and sarcoidosis examinations from 2013 and 2016 also have problems. Among other things, the examinations also merely restated the 2010 FEV-1, FVC, FEV-1/FVC, and DLCO (SB) studies. See June 2013 VA Examination; December 2016 C&P Exam. Finally, none of the examinations have considered medical records showing that the Veteran was using mometasone, which appears to be a steroid. See May 2020 CAPRI; October 2016 CAPRI; February 2013 Medical Treatment Records. For these reasons, among others, a remand is needed for new VA examinations. The Board notes that the 2020 examination stated that there were other nodules which may have been related to sarcoidosis, but that it was not possible to know because the required testing could not be done due to the pandemic. See June 2020 C&P Exam. VA treatment records from 2020 show that there was a plan to biopsy skin lesions for possible sarcoidosis, but the plan was deferred due to the pandemic. See May 2020 CAPRI. VA treatment records since 2020 have not been added to the claims file. These records may contain biopsy results to aid in determining whether other nodules are related to sarcoidosis. A remand will allow for updated VA treatment records to be obtained. See 38 C.F.R. § 3.159. The matter is REMANDED for the following action: 1. Provide the Veteran with an opportunity to identify any relevant outstanding private and/or VA treatment records, including but not limited to, treatment records concerning any convalescence required from right foot surgeries at any point since April 2011. After obtaining any necessary authorizations from the Veteran, make all reasonable attempts to obtain the outstanding records in accordance with 38 C.F.R. § 3.159. 2. Update VA and private treatment records. VA treatment records appear current up to June 2020. 3. Schedule one or more appropriate VA examinations to determine the nature and severity of the Veteran service-connected right foot plantar fasciitis disability from April 2011 to the present. This should include, but is not limited to, all muscle injuries and all neurological impairment. This should also include a discussion of any convalescence required from any right foot surgeries at any point from April 2011 to the present. The claims file and a copy of this Remand should be made available to and should be reviewed by the examiner. Any studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner providing the examination needs to be able to provide range of motion results for the right foot, unless it is determined that the medical community at large could not provide such results without resorting to speculation. The examiner should report all signs and symptoms necessary for evaluating the Veteran's service-connected right foot plantar fasciitis disability from April 2011 to the present. This should include, but is not limited to, any muscle injuries and any neurological impairments. The severity of any muscle injuries (i.e., slight, moderate, moderately severe, or severe) and the severity of any neurological impairments (i.e., mild, moderate, severe incomplete paralysis, or complete paralysis of the affected nerves) should be assessed. Identify the specific muscle groups associated with any muscle injuries and identify the specific nerves associated with any neurological impairments. This should also include all symptoms and related impairment that would have been present without the relief provided by medication to treat the disability. This should also include a discussion of any convalescence required from any right foot surgeries at any point from April 2011 to the present. The Board notes that the nature, severity, signs, and symptoms of the right foot plantar fasciitis disability may vary at different points during the appeal period. Such variations should be reflected in the examination report, if applicable. The examiner should provide range of motion measurements in degrees. In so doing, the examiner should test the Veteran's range of motion in active motion, passive motion, weight-bearing, and in non-weight-bearing. Such range of motion results should be recorded in the report. If there is evidence of pain on motion, the examiner should indicate the degree of range of motion at which such pain begins. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, the examiner should clearly explain why in the report. The examiner must comment on the functional limitations caused by repetitive use over time and flare-ups due to the Veteran's service-connected right foot plantar fasciitis disability. The examiner must indicate whether, and to what extent, the Veteran's range of motion is additionally limited after repetitive use over time and during flare-ups in terms of degrees, if possible. If it is not possible, the examiner should explain why, making clear that all procurable and assembled data (i.e., the information regarding frequency, duration, characteristics, severity, and/or functional loss related to repetitive use over time and flare-ups elicited from the Veteran) was considered, and that the medical community at large could not provide such an opinion without resorting to speculation. If it is not possible due to a deficiency in the record or a lack of personal medical knowledge, the examiner should state so. Any additional impairment on use or in connection with repetitive use over time and flare-ups should be described in terms of the degree of additional range of motion loss. If the Veteran states that the limitation on range of motion is variable, provide the range of variableness in terms of degrees. The examiner should specifically describe the severity, frequency, and duration of impairment after repetitive use over time and during flare-ups; name the precipitating and alleviating factors; and estimate, per the Veteran, to what extent, if any, such repetitive use over time and flare-ups affect functional impairment. This testing should be done regardless of whether the Veteran is tested after repetitive use over time or during a flare-up or not. The examiner should also provide estimates of what the Veteran's range of motion measurements, symptoms, and related impairment would have been from April 2011 to the present with and without the ameliorative effects of medication used to treat the right foot plantar fasciitis disability. In addition to the other relevant evidence of record, the examiner is asked to consider and address as appropriate the following information with a caution that this list is not a substitute for a review of the record: (1) A 2022 examination. See June 2022 C&P Exam. (2) A 2020 examination. See May 2020 C&P Exam. (3) Medical records from 2012 showing right foot numbness. Medical records from 2014 showed that a procedure on the bottom of the foot had occurred. The surgery for the right foot had occurred six months prior. Medical records from 2015 showed moderate right foot swelling. The Veteran used a cane while putting weight on the right foot. See May 2020 CAPRI. (4) The Veteran's report of using a cane and custom brace for the right foot for years. The foot would invert easily, and the Veteran would fall. There was no stability. The Veteran had fallen at home a lot. The condition had worsened since it had been rated moderately severe. See March 2020 Hearing Transcript. (5) Medical records from 2011 showing range of motion from five to 45 degrees of plantar flexion. Strength appeared decreased in eversion. Medical records from 2013 showed metal in the right foot. Further information is provided. See April 2017 CAPRI. (6) A 2015 examination. See February 2015 C&P Exam. (7) The Veteran's report of foot surgery in 2013 or 2014. See June 2014 NOD; January 2014 Statement in Support of Claim. (8) Medical records from 2013 showing that the Veteran ambulated with a slight drag of the foot and used a cane. See January 2014 CAPRI. (9) A 2013 examination. See March 2013 VA Examination. (10) Medical records from 2012 showing the Veteran's report of mainly walking on the toes to avoid pressure on the right heel. Morphine and hydrocodone were used. There was an antalgic gait and the Veteran stood plantarflexed on the toes with the heel pad resting. See February 2013 Medical Treatment Record. (11) Medical records from 2011 showing that the Veteran could not put any pressure on the heel due to severe pain. As a result, the Veteran walked on the right forefoot without the heel touching the ground and the foot pointed laterally. There was mild osteoarthritis involving the first metatarsophalangeal joint space. Medical records from 2012 possibly showed bone chips in the foot. See April 2012 CAPRI. (12) The Veteran's 2011 report of right foot injections. The Veteran wore a brace on the right foot which aggravated foot pain and had cortisone shots for right foot pain. See April 2011 Statement in Support of Claim. (13) Medical records from 2011 showing severe plantar fasciitis; ibuprofen; morphine; Vicodin; a recent cortisone injection in the foot; and tramadol for the right foot, which had been helping. The heel was noted to be less swollen, and the Veteran reported improvement in plantar fasciitis pain. The plantar fascia had been swollen and inflamed. The Veteran was waiting for surgery. Further information is provided. See April 2011 Medical Treatment Record; May 2010 Medical Treatment Record. (14) All other relevant lay and medical evidence. A complete and clear rationale for all opinions offered should be provided. Address the Veteran's documented history and assertions. The Veteran is competent to attest to factual matters of which the Veteran has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. All necessary tests and studies should be conducted. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner should provide an explanation stating why. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is due to the limits of the medical community's knowledge or due to the limits of the examiner's medical knowledge. 4. Schedule one or more appropriate VA examinations to determine the nature and severity of the Veteran service-connected asthma and sarcoidosis disabilities from April 2011 to the present. This should include new skin and scar testing for the sarcoidosis and new FEV-1, FVC, FEV-1/FVC, DLCO (SB), and exercise capacity studies. If the DLCO (SB) testing is not performed, explain why the test would not be useful or valid for the Veteran's particular case. If the exercise capacity testing is not performed, explain why the test would not be useful or valid for the Veteran's particular case. The claims file and a copy of this Remand should be made available to and should be reviewed by the examiner. Any studies, tests, and evaluations deemed necessary by the examiner should be performed. The Board notes that the nature, severity, signs, and symptoms of the asthma and sarcoidosis disabilities may vary at different points during the appeal period. Such variations should be reflected in the examination report, if applicable. The examiner should specifically identify each medication/treatment used for the Veteran's asthma and/or sarcoidosis at any point since April 2011; explain what kind of medication/treatment it is/was (i.e., systemic (oral or parenteral) high dose corticosteroids, immuno-suppressive medications, systemic (oral or parenteral) corticosteroids, systemic high dose (therapeutic) corticosteroids, etc.); and identify the frequency and duration in which the medication/treatment was used and/or was required since April 2011. The examiner should also provide estimates of what the Veteran's DLCO (SB) results would have been at various points during the appeal period when such testing was not performed. In addition to the other relevant evidence of record, the examiner is asked to consider and address as appropriate the following information with a caution that this list is not a substitute for a review of the record: (1) A 2022 examination. See June 2022 C&P Exam. (2) A 2020 examination. See June 2020 C&P Exam. (3) Medical records from 2011 showing left forehead soft tissue fullness which the Veteran reported to be a sarcoid lesion. Sarcoid granulomas appeared intermittently for months and then regressed. There was an assessment of "cutaneous sarcoidosis right heel lesion." Medical records from 2013 showed a history of "roid rage" from prednisone treatment for sarcoidosis. The last injection had recently occurred. There was a small dark skin area in the forehead, presumably from sarcoidosis. There was a tender nodularity at the right heel. Medical records from 2014 showed a history of sarcoidosis. The Veteran was started on azithromycin and educated on how to use albuterol. Medical records from 2015 showed that albuterol was available if needed. Medical records from 2017 showed that the Veteran did not like the dry powder inhaler mometasone for asthma. There was the possibility of considering a switch to budesonide/formoterol. There was a consult on options for inhaled steroids or combination treatment. Medical records from 2018 showed a small nodule on the left side of the forehead. Medical records from 2020 appeared to show that budesonide replaced mometasone in 2017 and 2019. Wheezing and presumed asthma responded to Symbicort and albuterol. The Veteran also had fluticasone at home. The Veteran reported scaly plaques on the knees and elbows in the past and was told that it was sarcoidosis. There was an impression of a sarcoidosis differential based on subcutaneous nodules on the lower back and chest wall. There was also a sarcoidosis flare-up. Psoriatic arthritis was checked for. There was an assessment of a history of sarcoidosis with nodules also seen in the lungs. There was concern that a rash was recurrent sarcoidosis. There was a plan to biopsy skin lesions for possible sarcoidosis. See May 2020 CAPRI. (4) The Veteran's report of coughing, shortness of breath, chest pain, night sweats, fatigue, wheezing, congestion, skin rashes, and joint pain. There was a sarcoid nodule on top of the right foot and one on the heel. The Veteran used Spiriva. The Veteran believed that it was a dry puff inhaler and a steroid. The Veteran had problems with steroids and would get "roid rage." There were bumps on the head, back, foot, right ankle, left foot, chest, and all over. See March 2020 Hearing Transcript. (5) Medical records from 2011 showing sarcoidosis with nodules in the heel. Mometasone was used as well. Medical records from 2012 showed a possible painful group of small marble sized masses on the left lower lumbar spine. See April 2017 CAPRI. (6) A 2016 examination. See December 2016 C&P Exam. (7) Medical records from 2016 showing the Veteran's report of using a mometasone inhaler all along. The Veteran would use it when needed. The Veteran had an allergy to steroids, but they helped with asthma symptoms. See October 2016 CAPRI. (8) Medical records from 2013 showing the use of mometasone. See July 2016 CAPRI. (9) The Veteran's report that there was pulmonary involvement requiring systemic high dose therapeutic corticosteroids for control. The Veteran was given prednisone early on for treatment and it caused an adverse reaction. The Veteran's body would not allow for higher doses to be taken. See May 2016 Statement in Support of Claim. (10) A 2013 examination. See June 2013 VA Examination. (11) Medical records from 2011 showing the use of mometasone for asthma and that it was a steroid. See February 2013 Medical Treatment Record. (12) Medical records from 2012 showing a symptomatic nodule on the right heel pad, which may have been a sarcoid nodule given a history of sarcoidosis. See February 2013 Medical Treatment Record. (13) The Veteran's 2012 report of a sarcoid lesion on the right heel. See March 2012 Correspondence. (14) Medical records from 2011 showing a history of sarcoid nodules with a sarcoid nodule under the heel of the left foot. See April 2011 Medical Treatment Record. (15) Medical records from 2011 showing two nodules in the bilateral heels. See May 2010 Medical Treatment Record. (16) All other relevant lay and medical evidence. A complete and clear rationale for all opinions offered should be provided. Address the Veteran's documented history and assertions. The Veteran is competent to attest to factual matters of which the Veteran has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. All necessary tests and studies should be conducted. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner should provide an explanation stating why. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is due to the limits of the medical community's knowledge or due to the limits of the examiner's medical knowledge. 5. Readjudicate the issues on appeal. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Dougan, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.